For each visit type in primary care during the COVID-19 pandemic where telehealth support was reported, benefits and drawbacks are outlined in this section. Table 4 provides a summary of the circumstances when telehealth was reported as suitable and not suitable per patient visit types during the COVID-19 pandemic. For more details on supporting evidence, please refer to Multimedia Appendix 8 [1,9,20-26,28-34, 39,40,44-48].

Chronic condition management visits in primary care were reported as being one of the visit types with the greatest number of studies reporting the use of telehealth during the COVID-19 pandemic (17/19, 89%). Of these 17 studies, 13 (76%) reported benefits and 6 (35%) reported drawbacks.

In the included studies, chronic condition management visits were often reported as suitable for telehealth because of a pre-existing patient-provider relationship, established diagnosis, and lack of complex physical examinations. Routine visits for chronic conditions (eg, diabetes checkups) could be facilitated using telehealth, as these tasks often relied on discussions (eg, diet and medication) [9,23,33]. Some of the examinations could be completed by patients at home under clinician guidance, such as foot examinations or weight measurements [1,18,20,22,27]. Patients could show their list of medications at home by reading the labels [22], and they could be educated on ways to use and administer medications at home (eg, asthma inhalers) and assisting with potential safety hazards or home support systems (eg, pets) [23]. Self-management education could also be enhanced if patients could share with their GPs during telehealth their home setting and at-home tools (eg, at-home blood pressure cuffs, glucose monitors, and heart rate monitors) [22].

A drawback of telehealth for chronic condition management in the included studies was when close monitoring (eg, complex comorbidities or cancer diagnoses) [30] or complex physical examinations (eg, pediatric examinations or smear examinations) were required [33]. Some patients reported being hesitant to use telehealth because of their unfamiliarity with the technology [21]. However, most patients with chronic conditions expressed high satisfaction and willingness to engage with telehealth again [31]. Patients with chronic conditions particularly favored the remote nature of telehealth as they were often at a higher risk of adverse symptoms if infected with COVID-19 when attending in-person clinics [21,23,28,29].

Existing patient consultations were reported as being one of the visit types with the greatest number of studies reporting the use of telehealth during the COVID-19 pandemic (17/19, 89% of the included studies). Of these 17 studies, 11 (65%) reported benefits and 1 (6%) reported drawbacks.

In the included studies, telehealth was reported as suitable for visits with a pre-existing patient-provider relationship as clinicians understood the patients’ history and had a pre-established rapport [1,23,24,27,32]. Issues primarily reliant on assessing visual symptoms, such as dermatological concerns, could be shared with clinicians via photos or video [32]. In some cases, clinicians reported higher efficiency using telehealth. They could reduce the downtime involved in transiting between different patients during in-person encounters and see more patients via telehealth [9].

In the included studies, existing patients reported satisfaction with telehealth, especially for straightforward matters (eg, medication refill) and patients at high risk of COVID-19 [24,26,30]. However, a drawback of telehealth was when new diagnoses were involved, even among people with pre-existing patient-provider relationships, because of the poor ability to conduct physical examinations [9].

Medication management consultations were reported as being one of the visit types with the greatest number of studies reporting the use of telehealth during the COVID-19 pandemic (17/19, 89% of eligible studies). Of these 17 studies, 11 (65%) reported benefits and 3 (18%) reported drawbacks.

In the included studies, telehealth was reported as making medication reconciliations easier, improving patients’ adherence to their medications [1,9,22,32]. Telehealth was reported as supporting prescription refills for patients familiar with the medication’s side effects and risks and for straightforward health concerns such as oral contraceptives [9,31,32]. Patients reported being satisfied with their telehealth experience related to medications [1,18,25]. For example, patients could share their medications at home via video and image sharing with their clinicians. Furthermore, clinicians expressed greater relief when not being pressured to prescribe addictive drugs to at-risk patients during telehealth [22].

Drawbacks reported in the studies included concerns when physical examinations were necessary (eg, checking for infections when prescribing antibiotics) and prescription of new medications [1,24,30]. Poorer communication in patient education of medications was also observed in some telehealth consultations, potentially affecting patients’ understanding of their medications [1,24].

New patient consultations with the use of telehealth during the COVID-19 pandemic were reported in 84% (16/19) of eligible studies. Of these 16 studies, 7 (44%) reported benefits and 9 (56%) reported drawbacks.

In the included studies, telehealth was reported as only suitable for new patients when the consultation focused on pre-existing diagnosed concerns, acute concerns (eg, dermatological concerns) that could be assessed via visual cues (such as via photo or video sharing), or when there was no need for physical examinations [1,23,25,27]. It is important to note that new patients are not always supported by health care reimbursement (eg, Medicare for Australian patients) outside certain criteria (ie, positive COVID-19 status, close contact, hot spot area, and emergency consultation), which affects the number of studies included for this visit type.

However, telehealth was reported as not suitable for new diagnoses when there was no pre-existing patient-provider relationship, lack of knowledge of patient history, or no pre-established patient rapport [1,22]. Telehealth for new patients would be particularly difficult when complex symptoms are involved or when patients are not forthcoming with their concerns (eg, feeling shy or experiencing language or cultural barriers). Managing new patients over telehealth would rely on trusting patients’ self-reported symptoms and patient-directed examination, which can become complicated when there is an absence of pre-existing knowledge of the patient [32]. In addition, technical problems within telehealth consultations can make building rapport with new patients even harder [33].

Mental health and behavioral management consultations with the use of telehealth during the COVID-19 pandemic were reported in 79% (15/19) of the included studies. Of these 15 studies, 11 (73%) reported benefits and 3 (20%) reported drawbacks.

In the included studies, telehealth was reported as only suitable for mental health and behavioral management when the consultation predominately focused on discussion and counseling activities [1,20,23,33]. Telehealth was suitable for patients with mild mental health issues (ie, patients not at risk to themselves or others), those without high cognitive impairments, and those who did not prefer a physical presence in consultations [20]. Studies involving patients with more complex mental health concerns referred to specialists (ie, psychiatrists) and participants in specialist mental health telehealth programs were excluded from this review. Patients with mental health concerns reported the benefits of reduced wait times when using telehealth during the COVID-19 pandemic, resulting in fewer barriers to accessing mental health care support [26,27]. Patients also reported being satisfied with their telehealth experience for mental health issues during the COVID-19 pandemic, particularly because of consultations being completed in a discreet manner (ie, the privacy of their own home) [1,9,24].

Drawbacks reported in the studies included patients’ hesitancy to disclose over telehealth because of the stigma around mental health concerns, cultural or language barriers, and confidentiality around disclosing sensitive matters where there was a lack of privacy at home [20,26]. It was challenging to conduct telehealth consultations with patients with unstable mental health concerns (eg, suicidal ideation) [1] or concerns requiring lengthier consultations [9]. There were mixed views about the need for physical examinations for screening tests [31].

Post–test result follow-up consultations with the use of telehealth during the COVID-19 pandemic were reported in 74% (14/19) of the included studies. Of these 14 studies, 5 (36%) reported benefits and 3 (21%) reported drawbacks.

In the included studies, post–test result follow-up was often suitable for telehealth as the primary activity involved discussions of test results rather than conducting physical examinations [22,23,26,32,33]. For patients and clinicians, practices used procedures to ensure confidentiality via telehealth when receiving (and discussing) test results [23]. For example, some practices used confirmation ID numbers or asked patients to confirm their date of birth before revealing sensitive medical information because of the absence of in-person confirmation [23]. In some cases, telehealth also improved the ability to share test results with patients compared with in-person consultations (eg, screen sharing of test results with patients over video consultation) rather than the patient attempting to reach over to read the test result on the GP’s computer screen during in-person encounters [26].

A drawback of telehealth reported for this visit type was the poorer communication patterns observed when explaining to patients complex medical jargon used in test results. This is possibly related to the impersonal nature of telehealth, the inability to use visual aids, the lack of a physical presence, or other elements required to explain test results remotely [33]. Other clinic staff may communicate test results if results are satisfactory or do not require additional follow-up, resulting in minimal benefit and drawback findings reported for this visit type. Unsatisfactory results may lead to GP-patient consultations, possibly resulting in more drawbacks reported for this visit type.

Postdischarge follow-up consultations with the use of telehealth during the COVID-19 pandemic were reported in 37% (7/19) of the included studies. Of these 7 studies, 5 (71%) reported benefits and 3 (43%) reported drawbacks.

In the included studies, telehealth was reported as suitable for postdischarge follow-up visits when patients lived far away or had difficulty arranging same-day or frequent follow-up visits (eg, antenatal visits) [23,26]. Patients with pre-existing patient-provider relationships linked to the same postoperative clinic also reported satisfaction [1].

However, there was the drawback of it being harder to coordinate care [1]. This visit type often involved multiple care team members and complex physical examinations by various clinic members (eg, nurses and practitioners to address wound care) [18,23]. It was also challenging to share documentation from multiple team members [23].

The NQF outcome measure “Access to care” (ie, the ability to receive health services promptly and appropriately) was reported in 84% (16/19) of the included studies. A summary of benefits and drawbacks of telehealth per this outcome factor is provided in Table 5.

Both patients and clinicians reported the benefits of using telehealth to maintain timely and frequent contact, shortening wait times in between visits and having a satisfactory experience [1,22,25,26,30,32]. Patients particularly enjoyed the additional benefits of reduced travel time [32,33], the convenience of being at home [23,31], having quicker access to care for simple concerns [1,26,29], and being able to access care that was only available for a teleconsultation but not available for in-person consultations (eg, outside clinic opening hours) [19,30], whereas clinicians reported the benefits of seeing more patients using telehealth [28] and connecting with patients who preferred technology over in-person encounters [9,25].

However, patients and clinicians reported insufficient technical support, infrastructure, or equipment to access telehealth and difficulty with more complex telehealth systems that required special hardware or software support [25,32]. Some patients reported difficulty finding privacy at home to attend teleconsultations [21]. Some patients felt excluded or deterred from seeking help because of unfamiliarity with technology [21,22]. Some clinicians reported drawbacks of telehealth, such as it being harder to address language or cognition barriers with patients without physical cues [22] as well as feeling concerned with risks on digital platforms (eg, cyberattacks, security, and confidentiality in web-based communication) [25].

The NQF outcome measure “Effectiveness” (ie, represents the systematic, clinical, operational, and technical success or barriers of telehealth) was reported in 84% (16/19) of the included studies. A summary of benefits and drawbacks of telehealth per this outcome factor is provided in Table 6. Both patients and clinicians reported that telehealth was suitable (ie, clinical appropriateness) for infections, dermatological concerns, renewal of prescriptions, or self-monitoring programs [25,32,33]. Most patients reported being sufficient at self-assessing whether they should seek a teleconsultation or an in-person consultation according to their health concerns [25]. Furthermore, patients could show their medication or self-care practices at home, allowing clinicians to better understand how their home environment may affect their self-management, thus improving clinicians’ advice dispensed to support their patients [1]. Clinicians also noted the benefits of sharing medical records with patients via screen sharing, improving their understanding [19].

However, telehealth was reported as not suitable for specific patient groups (eg, people with unstable mental concerns or low hearing and vision, young children unable to describe symptoms themselves, and people with cognitive impairment) [30] or for complex symptom presentations or diagnoses that required physical examinations (eg, chest pain, stomach pain, and potential new cancer) [1,9]. There is currently a lack of guidance on identifying and addressing severe adverse events that may occur because of telehealth (eg, lack of guidance on safety netting for teleconsultation, uncertainty about who else is also present but hiding during the teleconsultation, or recording consultations without consent) [1]. Furthermore, there is a tendency to rely more on patient-reported outcomes and patient-directed examinations during telehealth, affecting a GP’s assessment of the patient’s health status, which may inevitably result in in-person consultations later on despite having had a teleconsultation [25,33].

The NQF outcome measure “Experience” (ie, represents the usability and effect of telehealth on patients and providers) was reported in 89% (17/19) of the included studies. A summary of benefits and drawbacks of telehealth per this outcome factor is provided in Table 7.

Both clinicians and patients were satisfied with a perceived lower risk of infection transmission during the COVID-19 pandemic as a result of using telehealth [1,25-27,30,33]. Some reported feeling positive that they were able to maintain a patient-provider connection via telehealth during the COVID-19 pandemic [9,32,33]. Primary care clinicians reported several personal benefits of telehealth, including improved work-life balance and the ability to conduct some consultations more efficiently [33]. Clinicians also reported perceiving their patients as feeling more relaxed in their home environments compared with in-person consultations [33]. Overall, most patients reported having a satisfactory experience and a willingness to use telehealth again [21,24].

As reported by both clinicians and patients, the main drawback of telehealth was dissatisfaction with a lack of in-person physical examinations [24]. Some clinicians faced the additional drawbacks of addressing language or cultural barriers without in-person cues [23] and the lack of stimulating work when there was little in-person interaction with patients [9]. In addition, telehealth sometimes required clinicians to take on multiple roles in the practice to ensure it ran smoothly (eg, secretary, IT support, and clinician) [26,33]. Patients similarly needed to combat barriers such as the lack of opportunity to develop rapport with their clinicians, impersonal consultations [27], language or cultural barriers to disclosing issues, technological barriers, and confidential concerns during web-based communication via telehealth [23].

The NQF outcome measure “Financial Impact/Cost” (ie, potential cost savings or losses to patients, families, or providers) was reported in 63% (12/19) of the included studies. A summary of benefits and drawbacks of telehealth per this outcome factor is provided in Table 8. From the clinicians’ perspective, the infrastructure, processes, and long-term reimbursement models of telehealth were important considerations before its full potential and benefits could be unleashed [9,28]. For patients, removing the need to travel and reducing the loss of pay from taking time off work to attend in-person consultations were important drivers for choosing telehealth [34].

However, issues relating to long-term models of financing and reimbursing telehealth remained a major concern [25]. For both patients and clinicians, there were concerns that remain to be researched about the expensive costs of acquiring the necessary software, hardware, and infrastructure to set up telehealth when it is unclear whether telehealth will remain a permanent service delivery mode in the long term. Furthermore, there is potential for commercial entities to exploit the charging or provision of telehealth when there remains uncertainty from the government on its long-term funding model [25]. There were mixed views regarding whether patients were willing to pay the same rate for telehealth consultations when compared with in-person consultations or an alternative appropriate cost [31].

The results of our systematic review identified a lack of quality evidence on primary care visit types suitable for telehealth. Most of the included studies (13/19, 68%) were level-4 evidence (ie, case series or cross-sectional studies), which are subject to self-report bias. Furthermore, there is a lack of focus on how telehealth was used for different visit types in primary care. The saturation of level-4 evidence in this space conveys that these study designs are indeed the current state of the art, presumably from the relatively short time since the start of the pandemic as well as the lack of ability to conduct follow-up or person-facing studies because of social distancing restrictions. As we move into the era of living with COVID-19, studies with a longitudinal follow-up that focus on specific visit types are required to assess the long-term suitability of telehealth in primary care. In addition, there was a lack of research in the included studies reporting clinical outcomes related to telehealth use during the pandemic, presumably because, at the time of searching and writing (ie, early phases of the COVID-19 pandemic), studies assessing clinical outcomes of using telehealth during the pandemic would not have yet been available. When those studies become available, future systematic reviews may wish to assess clinical outcomes of using telehealth during the pandemic so that the findings in this review reporting the suitability of telehealth for primary care visits can be validated.

As a result of COVID-19, several countries (eg, Australia, the United States, and the United Kingdom) have introduced permanent or long-term funding for telehealth in primary care. For example, the Australian government introduced long-term funding for telehealth in December 2021 to align with initiatives to reduce community COVID-19 transmission [52]. Australians have welcomed telehealth consultations, with >86 million primary care telehealth consultations completed in Australia since the beginning of the COVID-19 pandemic [8]. Other countries such as the United States and the United Kingdom are exploring a permanent funding scheme for telehealth within their existing health care models. Almost every state Medicaid program has a reimbursement coverage account for telehealth services in the United States [53]. The Centers for Disease Control and Prevention also introduced multiple waivers during the COVID-19 pandemic to grant payment parity for telehealth [54].

Before the pandemic, telehealth policies in the United Kingdom alone were underdetermined across England, Wales, Northern Ireland, and Scotland. Challenges related to outdated systems and underinvestment in telehealth have hindered the progress of digitization [55]. During the COVID-19 pandemic, health care services under the National Health Service took a “total triage” approach where all patients were referred first to telehealth services over face-to-face services [55]. According to the Health Foundation, this initiative has caused a rapid and significant increase in telehealth use, reporting the highest-ever number of telephone consultations in English primary care as a consequence of the pandemic [56]. For example, a videoconferencing telehealth platform called “Near Me” reported having been used by approximately 300 people per week at the start of 2020, rising to approximately 20,000 appointments every week by mid-2020 [55]. By July 2021, >1 million appointments were delivered via telehealth services [55]. Furthermore, 11.4 million telephone consultations were reported to have been completed in March 2021 compared with 3.5 million in March 2019 [56]. This rapid and unforeseen uptake of telehealth services raises questions as to whether unintended consequences and safety risks may have been introduced as well [55].

Governments have recognized the value of telehealth during the pandemic, especially for patients who struggle with mobility [1,25], live remotely or rurally [15], or are unable to find suitable times to attend in-person consultations [8], regardless of their COVID-19 status. Future research ought to examine how long-term funding models of telehealth affect patient outcomes, help-seeking behaviors, and health service use patterns. For example, further research is required to compare the health outcomes and quality of care between patients who primarily use telehealth experiences versus those who use in-person care. In addition, further research is required to analyze how changes in health service use patterns because of routine telehealth use affect the funneling of resources, particularly training opportunities for health care providers on how to use telehealth optimally and the communication skills required in telehealth.

Furthermore, there is the additional consideration of how designs of telehealth need to evolve with emerging safety, ethical, and equitable concerns, for example, how to ensure that all patients can equally access care, regardless of the digital divide, if more resources are directed to providing telehealth over in-person services. In addition, further research is required to explore how to support patient-provider relationships when care is delivered across a blended model of approaches, as well as further research into appropriate safety-netting practices during teleconsultations [57].

Increasingly, care is moved closer to patients’ homes, blended with technology. The pandemic has accelerated the movement of blending care and technology at home. For example, home oximetry monitoring programs have been introduced for monitoring positive COVID-19 patients in the United Kingdom, and a recent prospective study has reported patient satisfaction and early success [58]. Other digital health services have also been increasingly introduced for use outside clinical settings, such as assistive technology to support independent living at home [13,59], remote monitoring mobile apps [60,61], and e–mental health services (eg, Betterhelp and Headspace) [52].

Introducing technologies directly into patients’ homes as part of routine service delivery may encourage more frequent monitoring of signs and symptoms. However, patient-facing medical devices and at-home care can introduce a new dimension of patient risk [62]. Historically, the role of conducting physical examinations and use of medical devices was reserved for health care professionals [63]. However, with telehealth and remote care services, the responsibility of physical examination and monitoring falls onto the patient, requiring patients to have the necessary knowledge and skills to conduct these previously clinician-directed tasks effectively by themselves or be aware of when to seek additional assistance [63]. As a result, patients could become vulnerable to unanticipated risks such as inaccurate self-examination [64,65], unreliable patient self-reports, reduced person-centered care because of language or cognitive barriers, inability to conduct a physical examination properly, or incapacity to receive care properly because of technological limitations [62,63]. Further investigation is required to identify the types of adverse events that can occur during remote care (eg, whether people are using technologies as intended or whether technologies are introducing unintended consequences) and ways to combat these adverse events [64].